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Riabilitazione in area critica e post-critica
Riabilitazione in area critica e post-critica
www.fisiokinesiterapia.biz
“The 5 year mortality rate in intensive care patientsis over 3 times that of the general population.”
Niskanen M et al. Crit Care Med 1996;24:1962.7.
“However at 2 year survival rates are parallel.”
Impact of Impact of RespiratoryRespiratory ComplicationsComplications on on LenghtLenght of Stay of Stay and Hospital and Hospital CostsCosts in Acute in Acute CervicalCervical InjuryInjury
Winslow C et al, CHEST 2002;121 1548Winslow C et al, CHEST 2002;121 1548--15541554
Sindrome da allettamentoFUNZIONI CARDIOVASCOLARI E COMPOSIZIONE SANGUIGNA•Diminuzione della gittata cardiaca, volume di eiezione e aumento della frequenza a cardiaca sotto sforzo•Rischio di tombosi
MUSCOLI SCHELETRICI•Diminuzione della massa muscolare•Trasformazione delle fibre IIb•Diminuzione del numero e della densità dei mitocondri
SISTEMA NERVOSO CENTRALE•Diminuzione dell’equilibrio in posizione eretta e durante deambulazione•Peggiorata esecuzione di test intellettivi
COMPOSIZIONE CORPOREA•Demineralizzazione ossea•Perdita di proteine•Diminuzione del contenuto corporeo di acqua e sodio•Perdita di peso e aumento della percentuale della massa grassa
FUNZIONI RESPIRATORIE•Diminuzione della CFR•Diminuzione della Compliance polmonare•Ritenzione secrezioni•Atelettasie
Allettamento
DE MATTIA E, PIAGGI G, NAVA S. Rass Pat App Resp 2001 15: 507-514
Sindrome da ImmobilizzazioneCause scatenanti
• Prolungato riposo a letto per il trattamento di una malattia in fase acuta
• Ipocinesia per una malattia primitivamente neurogena e miogena
• Mantenimento continuo di postura seduta o supina, in assenza di patologie rilevanti
• Assenza di gravità
Muscles Weakness in Mechanically Ventilated Patients
with Severe Asthma
JW Leathermann, et al. AJCCM 1996: 153:1686
Critical Illness Myopathy and Neuropathy (n=28)
MUSCULAR FAILURE
22%
61%17%
MiopathyNeuropathyMixed
SURVIVAL
17
7
DeadAlive
Latronico N. et al. Lancet 1996; 347, 1579
GOALS OF PR IN ICU
• Reduce secretions• Favour active mobilization and ADL• Improve muscle strength• Prevent bed-laying and embolism• Improve quality of life
CANDIDATES
Acute respiratory failureand/or monitoring
Weaning process
WHAT TO ASSESS ?Respiratory system
• SatO2• Chest X-ray• Use of respiratory accessory muscle• Signs and symptoms of:
– hypoxia– hypercapnia– right heart failure
SOLUTION 1
CHEST PHYSIOTHERAPY
SOLUTION 2
WEANING PROTOCOLS
WHAT TO ASSESS ?Peripheral muscle system
• Posture• Motility
SOLUTION 1
PASSIVE MOBILITY
SOLUTION 2
ACTIVE MOBILITYMUSCLE RECONDITIONING
ACTIVITIES• POSTURES
- Prone position- Rotational therapy
• CHEST PHYSIOTHERAPY- Drainage (suction, MH)- Percussions and/or vibrations- Rotational therapy
• MUSCULAR ACTIVITY- Respiratory muscles- Peripheral muscles
ACTIVITIES• POSTURES
- Prone position- Rotational therapy
• CHEST PHYSIOTHERAPY- Drainage (suction, MH)- Percussions and/or vibrations- Rotational therapy
• MUSCULAR ACTIVITY- Respiratory muscles- Peripheral muscles
Ausili per postura
• Pesi• Rulli• Cubi• Valve rigide• Cuscini • Materassi antidecubito
Effetto della postura del paziente
• 32 pts (24 M, 8 F, età media 55.9 aa)• IRA con PaO2/FiO2: <150 (non causato da ins.cardiaca o atelettasie)• PaO2/FiO2 passa da 103 a 158 in posizione prona dopo 1 h e a 159
dopo 4 hChatte G, Sab JM, Dubois JM, AJCCM 1997; 155: 473
Effect of lateral rotational therapy on the prevalence of VAP in long-term ventilated patients
Kirschenbaum L. et al CCM 2002; 30: 1983-1986
ACTIVITIES• POSTURES
- Prone position- Rotational therapy
• CHEST PHYSIOTHERAPY- Drainage (suction, MH)- Percussions and/or vibrations- Rotational therapy
• MUSCULAR ACTIVITY- Respiratory muscles- Peripheral muscles
0102030405060708090
100
UK Australia HK UK2
% of MH
L Denehy Eur Respir. J 1999
01020304050607080
secr
etio
ns
ATE
L:
FiO
2
coug
h
LV
CO
M.
ausc
ulta
tion
% of R
% of responders during Manual Hyperinflation (MH) in ICU
Effect of Combined Kinetic Therapy and Percussion Therapy on the Resolution of
actelectasis in Critically Ill Patients
Raoof S. et al CHEST 1999; 115: 1658-1666
ACTIVITIES• POSTURES
- Prone position- Rotational therapy
• CHEST PHYSIOTHERAPY- Drainage (suction, MH)- Percussions and/or vibrations- Rotational therapy
• MUSCULAR ACTIVITY- Respiratory muscles- Peripheral muscles
Effects of controlled inspiratory muscle training in patients with COPD: a meta-analysis
F Lotters et al (2002; 20:570-576)
BerryGoldesteinLarsontotal pimax > 60DekhuijzenWeankeWeinertotal Pimax < 60
-2 -1 0 1 2 3 Favours favourscontrol treatment
BerryGoldestein
total pimax > 60Dekhuijzen
Weinertotal Pimax < 60
-2 -1 0 1 2 3 Favours favourscontrol treatment
IMS EC
Design: prospective observational trial setting: ICUpatients: 10 pts who had failed to wean from MV with 2.1±3.4 h of SB.Interventions: IMST of 4 sets of 6 breaths with threshold with anintensity to yield an exertion rating of 6 to 8.
Results: IMST pressure from 7±3 cmH20 to 18±7; 9 out 10 weanedafter 44±43 days
CHEST 2002:122;192-6
Zanotti E at al. Chest 2003; 124: 292-296
PERIPHERAL MUSCLE STRENGTH TRAINING IN BED-BOUND COPD UNDER MVa RCT comparing Active Limb Mobilization (ALM) with ALM + Electrical Stimulation (ES)
PROGRAMMI DI RIABILITAZIONE NEL PAZIENTE VENTILATO INVASIVAMENTE
Terapia FisicaRicondizionamento Muscolatura Generale
Mobilizzazione passiva arti
Mobilizzazione attiva arti
Stazionamentoseduto
Stazionamentoeretto
Deambulazione assistita
Deambulazione autonoma
Dipendenza
Autonomia
Mobilizzazione
• Mobilizzazione passiva• Mobilizzazione passiva forzata• Mobilizzazione attiva
Acquisizione dell’ortostatismo
• Lettino di statica• Standing
PuleggioterapiaErcolina per arti
superiori
Letto di statica
Recupero della motricita’
• Parallele• Deambulatori - walker
- ascellare - articolato- rollator
• Tripodi, quadripodi• Antibrachiali• Bastoni• Scale
Zanotti E at al. Chest 2003; 124: 292-296
PERIPHERAL MUSCLE STRENGTH TRAINING IN BED-BOUND COPD UNDER MVa RCT comparing Active Limb Mobilization (ALM) with ALM + Electrical Stimulation (ES)
ALM/ES significantly ... decreased the number of days needed to transfer from bed to chair(10.75± 2.41 vs 14.33 ± 2.53 days, p 0.001).
Design: prospective randomized controlled trial Setting: RICUPatients: COPD recovering from ARF Interventions: early PRP vs Standard MT alone;
step 1: 2/d 30-45 min postural position, sitting in bed or chair, lower extremities training, postural drainage, coughstep 2: rolling , walk , step 3: muscle training, lower extremity training, cycling, climbingstep 4: treadmill sessions
Results: effort tolerance, MIP, dyspnoea were better for PRP group
Rehabilitation of patients admitted to a respiratory intensive care unit
Nava S. (Arch Phys Med Rehabil 1998; 79:849-854)
Rehabilitation of Patients Admitted to a Respiratory Intensive Care Unit
ns
P<0.0001 P<0.001
P<0.05
Nava S. Arch Phys Med Rehabil 1998; 79, 849-854
Arm training in patientsweaned from MV
Trial profile
Patients included n=66(spontaneous breathing sustained for
at least 48 consecutive hours)
PT + Arm trainingn=32
PT n=34
Pts. evaluablen=25
Pts. evaluablen=25
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Minutes Minutes
Watts Watts
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